Jr. Chiefettes Registration Form
Name: _________________________________ Grade: ___
Age: ____ School: _________________________________
Please circle child s size below. Order additional T-Shirts for only $7.00 Please circle additional size
T-Shirt Size: Youth S M L
Adult S M L XL
Parent/Guardian name: ________________________________
Contact Phone Number: _______________
Mailing Address: _______________________________
How did you hear about Jr. Chiefettes? ______________________
Please completely fill out the medical release form below and have
it notarized. We will have a notary present during registration on
Saturday, September 20, 2008.
School Board of Hillsborough County
MEDICAL RELEASE FORM
COMPLETE PART I OR II ONLY
The undersigned as the parents and/or legal guardians of ________________________do hereby consent to any and all medical and surgical treatments,
including anesthesia and operations, which may be deemed advisable by any qualified physician selected by agents or officials of the Hillsborough County
School Board. The intention hereof is to grant authority to administer and to perform all and singularly any examination, treatments, anesthetics,
operations, and diagnostic procedures, which may now or during the course of the patient s care, be deemed advisable or necessary by any qualified
physician. No action shall be taken until an attempt is made to contact me at the phone number(s) listed below:
IN WITNESS of our consent and agreement to the matters stated above, we have subscribed our signature below.
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
SUBSCRIBED and sworn to before me a Notary Public, this___________________day of _________________20________.
My Commission expires:
As parent or guardian of the athlete listed below, I do not desire to sign the medical and surgical release form above.
Name of Athlete__________________________________________Parent/Guardian______________________________________